Transcript

Norman Swan: A significant proportion of people with depression and anxiety in Australia go undiagnosed and untreated. Two barriers have been affording therapy and having access to professionals who can provide it.

Well a few days ago the Federal Government released the evaluation report into what's called the Better Access program. It's been in play for a few years and provides Medicare benefits to give people increased access to therapy from psychologists, GPs, social workers, occupational therapists and psychiatrists.

It's been controversial because some have said that using fee for service for payment entrenches uneven distribution and in terms of value for money, no one knows if people are actually receiving evidenced based treatment.

Professor Jane Pirkis of the Centre for Health Policy, Programs and Economics at the University of Melbourne led the evaluation.

Jane Pirkis: We were asked to bring together evidence from a whole range of sources so we had twenty different data sources to answer a range of evaluation questions. Some of those data sources came from studies that were specifically commissioned for the evaluation and others were studies that were done for another purpose but were able to inform the evaluation questions. So for example we conducted a completely new study looking at experiences of care and outcomes of care for consumers through Better Access.

Norman Swan: And what were the questions you were asking?

Jane Pirkis: We were asking questions about the extent to which Better Access was reaching people, and questions about the outcomes for people of Better Access.

Norman Swan: What were your main findings?

Jane Pirkis: Well we found very high levels of uptake so about 2 million people accessed services in 2007, 2008, 2009, so for that three-year period that 11 million services around half of the people who accessed services were people who had not accessed mental health services in the past. They were new to the mental health system. The vast majority of those people had high levels of clinical need 80% or higher in fact had high or very high levels of psychological distress when they started treatment and 90% or more had diagnoses of depression or anxiety.

And we also found importantly that the vast majority of the people in the group we followed experienced very positive outcomes. So I guess we concluded that Better Access was doing a very good job at meeting a fairly significant previously unmet need.

Norman Swan: But an unmet need in the cities. One of the criticisms here is because it was fee for service you were going to get the same mal-distribution of services that you get under the existing system which is the cities and the more well-off suburbs in the cities do quite well but outer-metropolitan and rural -- people living in those areas are still left a bit short.

Jane Pirkis: It's certainly true that people in the lowest socio economic areas and in remote areas received proportionally fewer services than those in more affluent city areas. But in absolute terms the number of services received and the number of people receiving services in those traditionally more disadvantaged areas were still quite high. So for example in 2009 150,000 people in the most disadvantaged areas across Australia received services which is far more than were receiving similar services pre Better Access.

Having said all that I think it is true that equity is an issue and I guess it's important to remember that Better Access is part of a suite of primary mental health care reforms. So I think there are complimentary programs out there.

Norman Swan: How much money does this scheme spend?

Jane Pirkis: Over the period we looked at about $1.45 billion was spent.

Norman Swan: So in a relatively small evaluation, it's not a randomised trial, their distress levels have gone down which is great and not to be knocked but it could have happened with hand holding and certainly for $1.4 billion you haven't got a clue what these psychologists, social workers and GPs are actually doing and whether they're giving evidence based care. In other words call it cognitive behavioural therapy, inter-personal psychotherapy, they're giving all sorts of stuff out there anecdotally.

Jane Pirkis: I think the key word is anecdotally. Although it's true we can't answer directly what consumers are receiving, we did ask providers to indicate what care they had delivered in the sessions.

Jane Pirkis: Well it's true but it's difficult to know how else we could have got that information and there was no incentive for the providers to be lying about what they were delivering.

Norman Swan: Well yes there is because they are being paid to do evidence based care, it's fairly explicit that that's what the government thinks they're buying isn't it?

Jane Pirkis: That's true but I still think you know there's a whole range of stuff that they could have been doing, we gave them a whole range of options and 85% of consumers received cognitive behavioural therapy albeit according to what the providers told us. The other thing to say is that we asked the consumers about the extent to which they would attribute any changes in their mental health to the care that they received and the vast majority again, about 75%, said they would attribute changes wholly or partially to the provider. So that's a good indication that the providers are doing something that at least the consumers feel is making a difference.

And then the third point to make is that we did see these positive outcomes. So I think when you take those three things together you'd have to suspect at least that the providers are doing something right.

Norman Swan: How solid were the improvements and how sure are you given that it was a non-randomised sample, almost self-selected in a sense by the providers? How sure were you that the improvements were actually valid?

Jane Pirkis: We used standardised outcome measures and a consumer rated measure. We selected our providers through Medicare and we did that through a random sample and the providers in turn selected the consumers for us but they followed a protocol to do that. So they selected consecutive consumers and they seemed to be doing that and the final thing to say I guess is that ultimately our consumer sample was pretty similar to the overall profile of Better Access users.

Norman Swan: If you talk to general practitioners what they often say is their problem is access to psychiatrists and often all they want is a psychiatrist to talk to, to check they are doing things the right way, or is this somebody who they should be worried about. And they complain bitterly that they can't get access to psychiatrists even for a quick consult -- has that changed for general practitioners?

Jane Pirkis: I honestly couldn't answer that question; we didn't ask that question in the evaluation.

Norman Swan: Professor Jane Pirkis is in the Centre for Health Policy, Programs and Economics at the University of Melbourne.

Guests

Professor Jane Pirkis

Centre for Health Policy, Programs and Economics,University of Melbourne

Further Information

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Comments (7)

Chris Ludlow :

21 Mar 2011 10:48:05pm

Thanks for reporting on this. I have two comments to make:

1) The study was an evaluation study. As such, Norman could have been a little more forgiving. Evaluation studies have many flaws. But they test for real-world effects and have high external validity. 2) Norman’s comments were slightly disparaging towards practitioners particularly when he questioned their use of evidence-based treatments. Many of these concerns are addressed by (a) the practitioners training, (b) professional association standards, (c) routine supervision, (d) continuing professional development, (e) the encouragement of psychologists to gain experience in post-graduate psychotherapy research, and (f) individual private practices routinely tracking patient symptoms overtime with standardized measures. I guess the point is this: practitioners do not operate in a vacuum doing what ever they want. Rather, practitioners are trained, have professional standards, and operate within a professional community.

Nevertheless, it was a great interview. And I do love Norman’s rigorous scientific approach towards his reports.

Henry Lomax :

23 Mar 2011 12:37:42pm

I thought the results of the research sounded overwhelmingly positve for people who need to get treatment but I counldn't understand why Norman was so derisive and frankly quite rude to the researcher who was presenting the information

Rural Psychologist :

23 Mar 2011 4:55:38pm

I am a psychologist and I know plenty of psychologists who do very little evidence-based work. CBT is a broad term that covers too much. Four years + 2 supervision does not normally mean psychs have sufficient training in the scientist-practitioner model; they need a Clinical Masters. One of the problems with Better Access is that most GP's have no clue about how to diagnose mental disorders. Many people I speak to have treated people under Medicare who do not officially qualify for the service (i.e., subclinical sxs). That's okay from a prevention point of view but it's still unethical.

Chris Mackey :

28 Mar 2011 4:29:14pm

Evaluation research conducted in a group specialist psychology practice in Geelong supports the findings of the official evaluation of the Better Access scheme. At Chris Mackey and Associates we have now gathered data on over 525 adult clients which demonstrate that the average client reported a reduction in depressive symptoms from a moderate level before treatment to a non-clinical or normal level after an average nine sessions of psychological therapy. Their initial symptom levels were clearly non-trivial. Given that previous research suggests that employees with untreated depression show reduced productivity which may cost their organizations approximately $10000 per year on average, these findings also hint at the potential cost-effectiveness of the nationwide Medicare-funded scheme. It is noteworthy that those clients we have treated for depression have fared just as well regardless of whether they were on prescribed medication. We have begun to present such findings at scientific conferences including the national conference of the Australian Association for Cognitive and Behavioural Therapy. Our data in the form of conference slides can be accessed at http://www.chrismackey.com.au/pdf/benchmark_data.pdf.

Pertinax :

There are problems with such self reporting and it is very subjective. Patients will like any interest shown in their complaints whether or not it is really medically beneficial compared a placebo.

In Germany where Homeopathy is covered by health insurance such studies show the majority of patients who receive Homeopathy report that it is very effective. And the insurers like it because it is cheaper than doctors.

Chunga :

18 Apr 2011 9:00:33am

One of the main criticisms i continue to hear of the Better Outcomes schemes is regarding treatment not reaching people in rural and socioeconomically disadvantaged areas. This is no doubt the case, but whether this can be attributed to a failure of the scheme or whether it is due to other factors is another question. Differences in help-seeking behaviours, willingness to go to see a psychologist come in to play. In terms of socio-economics, I know several psychologists who bulk-bill clients who have financial difficulties, are unemployed, or on a pension. I do also know that many don't. A lack of rural based support is not just related to a fee for service scheme. There are always plenty of rural positions available for psychologists within departments of health and education as well as other sectors. Like many other professions in our country, teachers, doctors, nurses etc, there are a shortage of people who are willing to move to a rural area to work. These are broader social problems than being due to the flaws in the Better Access Scheme.

Andrew :

19 Apr 2011 5:40:11pm

Its a real shame that the focus of this story was evidence-based treatments and whether or not providers are giving them. This is old news. It's been pretty comprehensively shown (e.g. Bruce Wampold) that 'common factors' account for the bulk of variability in psychotherapy outcome - not particular brands of treatment (such as CBT). Even more disappointing was the sub-text that psychologists and allied health providers somehow can't be trusted and that if only doctors (GPs)could talk to other doctors (psychiatrists) then everything woudl be fine. Well the reality is that there are not enough psychiatrists and GPs are not trained (nor do they have the time) to provide adequate psychological care. I'm a psychology student and I'm constantly amazed at the ridiculous self-serving infighting that goes on in the mental health field. Shouldn't we all be cheering that 2 million Australias(or however many it was) people got treatment that worked for them and as a result as less distressed?